FOREIGN BODY AIRWAY OBSTRUCTION(FBAO)CHOKING

INTRODUCTION Choking is the physiological response to sudden airways obstruction. Foreign body airway obstruction (FBAO) causes asphyxia and is a terrifying condition, occurring very acutely, with the patient often unable to explain what is happening to them. If severe, it can result in rapid loss of consciousness and death if first aid is not undertaken quickly and successfully. Immediate recognition and response are of the utmost importance. Choking due to inhalation of a foreign body usually occurs whilst eating; it need not have been a formal 'sit-down' meal - a snack eaten 'on-the-go' or chewing gum can also be inhaled. DEFINITION Partial or complete blockage of the breathing tubes to the lungs due to a foreign body (e.g., food, a bead, toy, etc.) The onset of respiratory distress may be sudden with cough. There is often agitation in the early stage of airway obstruction. The signs of respiratory distress include labored, ineffective breathing until the person is not longer breathing (apneic). Loss of consciousness occurs if the obstruction is not relieved. EPIDEMIOLOGY Frequency Most airway foreign body aspirations occur in children younger than 15 years; children aged 1-3 years are the most susceptible. Vegetable matter tends to be the most common airway foreign body; peanuts are the most common food item aspirated. The incidence of metallic foreign body aspirations, particularly of safety pins, has decreased in frequency secondary to the advent of disposable diapers.Incidence Choking is a risk whenever food is consumed. A US study suggests an incidence of death due to FBAO of 0.66 per 100,000 population.5 An Australian study looking at incidence of foreign body asphyxia admission rate in the under-15s shows a rate of 15.1 per 100,000 per annum, peaking in those aged under one and then gradually declining to low levels by 3 years old. ETIOLOGY Young children comprise the most common age group for foreign body aspiration because of the following:
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They lack molars for proper grinding of food. They tend to be running or playing at the time of aspiration. They tend to put objects in their mouth more frequently.

They lack coordination of swallowing and glottic closure. RISK FACTORS

In one Austrian autopsy series, certain risk factors were identified:

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Old age Poor dentition Alcohol consumption Chronic disease Sedation Eating risky foods

FBAO was diagnosed correctly in fewer than 10% of cases where help was summoned. The elderly are a particularly vulnerable group and FBAO is associated with
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A higher risk with soft/slick foods. Agomphiasis (absence of teeth). Neurological impairment.

Children, in particular mobile babies and toddlers who orally explore their environments, are at risk from FBAO. Carers need to maintain vigilance for objects such as coins, balloons, marbles. Risky foods in childhood tend to be round in shape and include sweets, nuts, grapes and improperly chewed other food. DIFFERENTIAL DIAGNOSIS Rapid evaluation is key: swiftly consider other conditions that may cause sudden respiratory distress, cyanosis or loss of consciousness, such as:
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Anaphylaxis Syncope Myocardial infarct Seizure

RELEVANT ANATOMY Airway foreign bodies can become lodged in the larynx, trachea, and bronchus. The size and shape of the object determine the site of obstruction; large, round, or expandable objects produce complete obstruction, and irregularly shaped objects allow air passage around the object, resulting in partial obstruction.

RECOGNITION Because recognition is the key to successful outcome, it is important to ask the conscious victim "Are you choking?". This at least gives the victim who is unable to speak the opportunity to respond by nodding! Consider the diagnosis of choking particularly if:
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Episode occurs whilst eating, and onset was very sudden. Adult victim - may clutch his or her neck, or points to throat.

Child victim - there may be clues, e.g. seen eating or playing with small items just before onset of symptoms.

Assess severity
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Mild obstruction: o The patient is able to breathe, cough effectively and speak. o Children are fully responsive, crying or verbally respond to questions, may have loud cough (and able to take a breath before coughing). Severe obstruction is indicated by: o Victim unable to breathe or speak/vocalise. o Wheezy breath sounds. o Attempts at coughing are quiet or silent. o Cyanosis and diminishing conscious level (particularly in children). o Victim unconscious.

PATHOPHYSIOLOGY After foreign body aspiration occurs, the foreign body can settle into 3 anatomic sites, the larynx, trachea, or bronchus. Of aspirated foreign bodies, 80-90% become lodged in the bronchi.

In adults, bronchial foreign bodies tend to be lodged in the right main bronchus because of its lesser angle of convergence compared with the left bronchus and because of the location of the carina left of the midline. Several papers have demonstrated equal frequency of right and left bronchial foreign bodies in children. Larger objects tend to become lodged in the larynx or trachea.

PRESENTATION In general, aspiration of foreign bodies produces the following 3 phases:

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Initial phase - Choking and gasping, coughing, or airway obstruction at the time of aspiration Asymptomatic phase - Subsequent lodging of the object with relaxation of reflexes that often results in a reduction or cessation of symptoms, lasting hours to weeks Complications phase - Foreign body producing erosion or obstruction leading to pneumonia, atelectasis, or abscess

Clinical presentation depends on the location of the foreign body. A large foreign body lodged in the larynx or trachea can produce complete airway obstruction from either the dimensions of the object or the resulting edema.
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Laryngeal foreign bodies present with airway obstruction and hoarseness or aphonia.

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Tracheal foreign bodies present similarly to laryngeal foreign bodies but without hoarseness or aphonia. Tracheal foreign bodies can demonstrate wheezing similar to asthma. Bronchial foreign bodies typically present with cough, unilateral wheezing, and decreased breath sounds, but only 65% of patients present with this classic triad.

Foreign body aspiration can mimic other respiratory problems, such as asthma. Foreign body aspiration differs in the presence of unilateral wheezing and decreased breath sounds. MANAGEMENT Treatment of airway obstruction due to a foreign body includes:
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Adults: The Heimlich maneuver. Children over 1 year of age: A series of 5 abdominal thrusts (a children's version of the Heimlich maneuver

Infants under 1 year of age: A combination of 5 back blows (with the flat of the hand) and 5 abdominal thrusts (with 2 fingers on the upper abdomen).

Adults
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In mild obstruction, encourage the patient to continue coughing, but do nothing else except monitor for deterioration. In severe obstruction in a conscious patient: o Stand to the side and slightly behind the victim, support the chest with one hand and lean the victim well forwards (so that the obstructing object comes out of the mouth rather than going further down the airway). o Give up to five sharp back blows between the shoulder blades with the heel of your other hand (checking after each if the obstruction has been relieved). o If unsuccessful, give up to five abdominal thrusts. Stand behind the victim (who is leaning forward) put both arms around the upper abdomen and clench one fist, grasp it with the other hand and pull sharply inwards and upwards. o Continue alternating five back blows and five abdominal thrusts until successful or the patient becomes unconscious. In an unconscious patient:
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Lower the patient to the floor. Call an ambulance immediately. Begin CPR (even if a pulse is present in the unconscious choking victim).

Children
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If coughing effectively, just encourage the child to cough, and monitor continuously. If coughing is, or is becoming, ineffective, shout for help and assess the child's conscious level. If the child is conscious, give up to five back blows, followed by five chest thrusts to infants or five abdominal thrusts to children (repeat the sequence until the obstruction is relieved or the

patient becomes unconscious). o For infants (<1 year old): back blows and chest thrusts:  In a seated position, support the infant in a head-downwards, prone position to let gravity aid removal of the foreign body.  Support the head by placing the thumb of one hand at the angle of the lower jaw, and one or two fingers from the same hand at the same point on the other side of the jaw. Do not compress the soft tissues under the jaw, as this will aggravate the airway obstruction.  Deliver up to five sharp blows with the heel of your hand to the middle of the back (between the shoulder blades).  After each blow, assess to see if the foreign body has been dislodged and, if not, repeat the manoeuvre up to five times.  After five unsuccessful back blows, use chest thrusts: turn the infant into a headdownwards supine position by placing your free arm along the infant's back and encircling the occiput with your hand. Support the infant down your arm, which is placed down (or across) your thigh. Identify the landmark for chest compression. This is the lower sternum, about a finger's breadth above the xiphisternum. Deliver five chest thrusts. These are similar to chest compressions for CPR, but sharper in nature and delivered at a slower rate. o For children (1 year old to puberty): back blows and abdominal thrusts:  Blows to the back are more effective if the child is positioned head down. A small child can be placed across the lap as with an infant. If this is not possible, support the child in a forward-leaning position.  Deliver up to five sharp back blows with the heel of one hand in the middle of the back between the shoulder blades.  After five unsuccessful back blows, abdominal thrusts may be used in children over 1 year old:  Stand or kneel behind the child, placing arms around torso. Placed clenched fist between the umbilicus and xiphisternum (ensuring no pressure is applied to either landmark).  Grasp this hand with your other hand and pull sharply inwards and upwards, repeating up to 5 times. If the child becomes unconscious, place him or her on a flat, firm surface, shouting for help if none has arrived. Open the mouth and look for any obvious object. If one is seen, make an attempt to remove it with a single finger sweep (don't do blind finger sweeps). If unsuccessful, begin CPR as for paediatricbasic life support,beginning with five rescue breaths, checking for rise and fall of the chest each time (reposition the head each time if a breath does not make the chest rise, before making the next attempt).

COMPLICATIONS
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Inhaled foreign body: after successful treatment for choking, foreign material may still be present in the upper or lower airways and cause complications such as bronchiectasis or lung abscess later. Anyone with a persistent cough, difficulty swallowing, or with the sensation of an object being still stuck in the throat should therefore be referred to A&E. CXR may show an opacity that requires removal at bronchoscopy or atelectasis. In children, clinical features and radiological findings may have a poor correlation with findings at bronchoscopy. If a foreign body is suspected, bronchoscopy should be performed at an early stage for best results.

Iatrogenic: abdominal thrusts can cause serious injuries (e.g. gastric and splenic rupture) and all victims receiving abdominal thrusts require examination of the abdomen with a particular view to visceral injuries. Hypoxic brain injury and death.

PREVENTION Tragedy due to FBAO is unpredictable. In our risk-averse society, we can try to iron out some elements of increased risk, such as:
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Not eating whilst exercising. Remembering to chew food properly. Avoiding drunkenness. Cutting up grapes and not giving peanuts to small children.

We can also increase public awareness of choking and confidence at initiating first aid. The abdominal thrust manoeuvre used in the pre-hospital setting on adults has a good rate of success (86.5%) Given the speed with which individuals lose consciousness and die in a complete airway obstruction and the fact that survival often requires obstructions to have been cleared prior to the arrival of paramedics,these skills should be widely taught and practiced.